Date: September 21, 2018
To: All Medical Assistance Providers
Re: Stage 4 Cancer Medications
Effective on January 1, 2019, Public Act 100-1057 prohibits the Department and other health insurers from limiting or excluding coverage for a drug approved by the United States Food and Drug Administration for treatment of stage 4 metastatic cancer by either:
· Mandating that a participant with stage 4 metastatic cancer first be required to fail to successfully respond to a different drug; or
· Proving a history of failure of the different drug.
This provision applies as long as the use of the drug is consistent with best practices for the treatment of stage 4, advanced metastatic cancers and is supported by medical literature published in peer-reviewed journals.
The Department follows National Comprehensive Cancer Network (NCCN) guidelines in the prior authorization process for cancer treatment, and as such, is already in compliance with this requirement.
Teresa T. Hursey